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SAN JOAQUIN COUNTY E NMENTAL HEALTH DEP AR NT <br /> MASTERME RECORD INFORMATION FORM <br /> �E$Vew EH Program and New Facili <br /> ❑New EH Pro am at Existin Facili <br /> ty <br /> I Program Record ID <br /> Facili ID J <br /> Facility Address 2s'LD <br /> (Please Check the appropriate description and specify size•number u°_and <br /> units Dertinent information.) <br /> e required <br /> FOOD PROGRAM(1600) Square Footage Food Handlers Cours : ❑ <br /> C3 Restaurant: Seating Capacity C3 with Food Preparation ❑Vending Machines—Number of Units [I No <br /> E3 Commissary E3 Dry storage only <br /> ❑ Multiple Departments <br /> [3 with Meat Market only Color[I Prepackaged Goods Only <br /> El Retail Market----Square footage Vehicle Type g[icker# �— <br /> ❑ Mobile Food Vehicle-----Make License# Color <br /> Registration# Vehicle Type <br /> Sticker# <br /> [3 Mobile Food Prep Unit--Make License# ❑ Ice Plant <br /> Registration# to <br /> -----Dates of operation from ❑ Produce Stand <br /> (3 Temporary Food Facilityto <br /> ❑ Special Event --Dates of operation from <br /> DAIRY�IAM(2000) ❑ Grade B Dairy E3 Milk Dispenser---Number of Containers in Multi-Head Unit <br /> ❑ Grade A Dairy CO/6U �A/113 P <br /> COPA El State Facility Surcharge(2399) [3 Recycle/Exempt System(2299) <br /> HAZARDOUS WASTE PROGRAM(2200) Generated Per Year <br /> ❑ Hazardous Waste Generator----------- Tons❑ Silver Only(2222) ❑ Appliance Recyclers(2217) <br /> ❑ CRT Offsite Handlers --- <br /> Tiered Permitting Facility---- ❑ Conditionally Authorized it ❑ Condit-By-Rule Household Hazardous Waste <br /> ❑Permit-By-Rule Fixed Unit ❑ Permit-By- <br /> AST <br /> ❑ ABOVEGROUND STORAGE TANK FACILITY(AST)(2390)UNDERGROUND STORAGE TANK(UST)PROGRAM(2 00)Use_USTAf�rms <br /> HOUSIN.�(2400) <br /> ❑ Jail or Exempt institution-------Number of Units <br /> ❑ Hote1/Motel-------Number 01 units Camp Apulicatioa Form <br /> Employee Housing(2700) Use a. anup,Site <br /> SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) <br /> [3Environmental Assessment ElUST-CAPSite ❑ Local HW[3 RWQCBICIeanupte ❑SiNPL/S❑ Water QuaCie lity Remediation on S to <br /> El Abandoned HW Site El non-NPL/SEP Cleanup Site <br /> RECREATIONAL HEALTH PROGRAM(3600) Cl out of Service Pool/Spa ❑ Natural Bathing Area <br /> Number of pools/Spas at Facility <br /> 1:1 Pool ❑ Spa <br /> VECTOR CONTROL PROGRAM(4000) ❑ Kennel <br /> ❑ Poultry Farm------Maximum number of birds <br /> TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM(4100) ❑ Permanent Cosmetics(4122) <br /> ❑ Tattooing(412 1) ❑ Body Piercing(4120) <br /> LIQUID WASTE PROGRAM(4200) License# Capacity Vehicle# <br /> ❑ Pumper Vehicle--Registration if [3 package <br /> `s--Treatment Plant ❑ Chemical Toilets-------Number of Units <br /> ❑ Pumper Yard <br /> SOLID WASTE PROGRAM(4400) El Sludge/Ash Site <br /> ❑ Transfer Station [1 Ag/Cannery Waste Site <br /> ❑ Landfill ❑ process/Recycle Facility 13 CIA Landoll Site <br /> ❑ Waste Tire Facility ❑ Compost Facility <br /> El Refuse Vehicles--Number of Units [3Dumpsters>20 cu yd----Number of Units ❑ Fartll/Ranch Cleanup Site <br /> MEDICAL PROGRAM(4500) <br /> WASTE ❑ Limited Hauler <br /> ❑ Primary Care LJ Acute Care ❑ Skilled Nursing ❑ Large Generator 13 Small Generator <br /> [3 Common Storage Facility-----❑ 2- 10----❑ 11 -60—O>60 generators <br /> ❑ Transfer Station ❑ Veterinary Clinic <br /> PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS END 46-02-003 Blue Application Fornl <br /> EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br /> Day Ph Night Ph <br /> CONTACT PERSON 11tom. <br /> PROGRAM ELEMENT 1-I Z) FEE W.Surcbargte F E E 13 Other FEE <br /> INSPECTOR# Arlt C� / PERMIT VALID Z t0 a J ❑ Food Handler <br /> ❑ Check# AMOUNT PAID Date INVOICE# <br /> ❑ Cash REVIEWED BY rn- ACCOUNTING OFFICE Date <br /> 48-02-034 Masterfile Record Pink <br /> 10/6/2003 <br />